Provider Demographics
NPI:1568574895
Name:CROGH, CONSTANCE LILLIAN (PT)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:LILLIAN
Last Name:CROGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2041
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-2041
Mailing Address - Country:US
Mailing Address - Phone:208-634-8517
Mailing Address - Fax:208-634-5763
Practice Address - Street 1:411A DEINHARD LN
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4800
Practice Address - Country:US
Practice Address - Phone:208-634-8517
Practice Address - Fax:208-634-5763
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist